Ninety percent of all people who die by suicide have a diagnosable psychiatric disorder at the time of their death.

The statistic is used to imply that, first, mental illness, and not individual choice, is the
cause
of suicide, and is often cited to justify coercive suicide prevention policies; and, second, that money invested in mental health treatment will reduce suicides. I wish to question the reliability of this statistic, as well as the two implications that are often drawn from it.

What is the source of this alarming statistic? It may surprise advocates of evidence-based medicine to learn that many of the source studies hardly qualify as scientific studies at all, in that many of them are
entirely uncontrolled. The studies rely on a technique known as a "psychological autopsy," which tries to diagnose mental disorders in a deceased person based on interviews with family members. The so-called first generation of studies simply chose a study group of known suicides, and tried to identify mental disorders within the study group, with
no control at all.
This 1996 study, for instance,
has no control, but purports to find that 90.1% of suicides have a diagnosable Axis I mental disorder.
This is the study that the National Institutes of Mental Health cite as their basis for the figure!

A new generation of studies "during the last decade" has attempted to apply basic scientific control procedures, however. In these studies, a group of known completed suicides was matched with a control group of
living
people with similar characteristics. Interviews, medical records, and "information from the coroner" are collected and evaluated by psychiatrists who are often supposedly "blind to outcome" - that is, they are not supposed to know who is a suicide and who is alive. If an evaluator knew someone was a suicide, he might be predisposed to look extra hard for information indicating a psychiatric disorder.

Keeping evaluating psychiatrists outcome-blind seems like a particularly difficult task, especially given that "information from the coroner" is included in the case reports. More importantly, those
preparing
case reports are necessarily not outcome-blind. The idea that their preparation would not be influenced by knowledge of outcome (suicide or living) is rather hard to swallow.

At any rate, one (dubiously)
controlled study of young men
found that 88% of the suicides, compared with 37.3% of the non-suicides, had a diagnosable mental disorder. To report this study as finding that "90% of suicides have a diagnosable mental disorder" is to ignore its more important implications: well over a third of this population of young males has a mental disorder! But 37.3% of young men do not commit suicide. Clearly, mental illness is not much of a "cause" of suicide. Some scientists characterize it as a necessary but not sufficient condition.

It is also important to point out what counts as a mental disorder in these studies. Depression counts, but also
alcohol or drug dependence, and often
any
Axis I or even Axis II disorder (as in the study of young men). It is instructive (and suspicious) that the percentage of suicides found to have a "mental disorder" does not seem to vary depending on the investigator's definition of "mental disorder."

It is also important to think about the vague, unscientific definitions of mental disorders found in the DSM-IV and its earlier incarnations. Given the vague definition of depression, for instance, is it really any surprise that people who commit suicide would meet the criteria for depression? (Actually, studies vary extremely widely in how many suicides they find to have been depressed -
all the way from 30% to 90%. Personality disorders vary even more widely - from 0% to 57%. This variance should make us very suspicious.) What person deciding to end his life
wouldn't, for example, experience a loss of pleasure in ordinary activities, or changes in sleep or appetite, or feelings of hopelessness or guilt? As for drug and alcohol use, what person, faced with the desire to die, wouldn't try to assuage his pain by any means available - including alcohol and drugs? In my own case, as a suicide, I view alcohol and drugs as a temporary suicide prevention device.
Recent research
in nicotine use, for instance, has revealed that nicotine may help symptoms like anxiety and depression, and help people with ADHD to function:

An even more important reason for the link between depression and smoking may stem from the pleasure that smoking can bring. As Dr. Fowler's research suggests, smoking triggers higher dopamine levels in the brain; elevated levels of dopamine have been linked to feelings of well-being and pleasure and have been found in users of heroin and cocaine. Such emotions may be particularly welcome by individuals suffering from depression.

I would like to point out that I do not smoke. But it is easy to see how this logic would apply to alcohol and other drugs. We should expect suicidal people to be more willing to experiment with illicit ways of promoting happiness, compared to the general population. To say that people who commit suicide are likely to have used drugs or alcohol is not to say that alcohol or drug use
caused
suicide.

Does investing money in mental health care prevent suicide? The relationship is shaky at best. The Japanese government's recent efforts to reduce suicide, through both coercive and non-coercive means, including increased mental health spending, have
failed miserably. A 2005 study published in JAMA found that "despite a dramatic increase in treatment, no significant decrease occurred in suicidal thoughts, plans, gestures, or attempts in the United States during the 1990s." While the frequency of treatment of individuals who engaged in suicidal behavior more than
doubled, the suicide rate dropped only 6%.

The statistic that 90% of suicides have a diagnosable mental illness, so gleefully reported by those in the anti-suicide industry, is questionable. Even if it has some basis in fact, vagueness of diagnostic criteria and other special factors detract from any conclusions that can be drawn from it. What is most uncertain is whether investing in mental health treatment actually reduces suicide. (This is made even more uncertain by the
failure of mental health treatment
even to, well, treat mental illness.)

A more realistic and ethical route would be to accept suicide as a relatively rare but natural and acceptable way to end life, to provide means of suicide that are effective and
not harmful to bystanders, to allow competent adults to opt out of coercive suicide "rescue," and to focus any government or private spending on alleviating
suffering, rather than preventing suicide.

See also:
What the DSM-II Got Right, my examination of changes in the diagnostic taxonomy for depression since the DSM-II and their implications for suicide rights.

Update: Jason Malloy points me to
this 2004 meta-study, studying suicides in North America, Australia, Europe, and Asia. "Twenty-seven studies comprising 3275 suicides were included, of which, 87.3% (SD 10.0%) had been diagnosed with a mental disorder prior to their death," say the authors. This is far superior to the studies that attempt to backwards-infer mental illness. My main problem with this study is that it’s tracking any and all “mental disorders” and even crap like “alcohol use” is coded as a disorder, not to mention “intermittent depressive disorder” and “neurotic depression” (i.e., they’re not even using the piss-poor standards of the DSM-IV).

7 comments:

I'd love to hear your thoughts on Thomas Szasz's more radical critique. Szasz writes specifically about psychiatry and the ethics of suicide in his 1999 book "Fatal Freedom," which I have not read. My understanding is that he defends suicide as an autonomous moral choice which people should be free to pursue in accordance with their values (DSM be damned!), though he is skeptical of physician-assisted suicide (at least as an state-endorsed institutional practice) because of its potential to medicalize moral conduct and to vest doctors with power that is likely to be abused.

Hey Chip, I haven't read a single book of Szasz, but he seems to be pointed in the same direction I am, but as you say, more radical. I'm open to biological explanations for mental illness (and there seem to be a few clear cases where there's a biological basis for the problem which the subject perceives as a problem, and a medical intervention actually works to solve the problem), and I think people should be free to choose medical interventions if they want. I think forcing interventions on people when they don't want them, though, is a load of crap, even if there were an intervention that had a 100% success rate and no side effects. I think people have a right to think and act in "crazy" ways. Also, psychiatric interventions like counseling have been shown to do approximately nothing. There's new evidence that many antidepressants do nothing, too. I wouldn't go as far as Szasz that psychiatry is purely unscientific and religious, but it clearly has its roots in non-science and, later, pseudo-science. I love Freud's writing, but he's not doing science.

So the problems are:1. It's not really science at this point2. Even to the degree it's science, it's miserably coercive, which is wrong

though he is skeptical of physician-assisted suicide (at least as an state-endorsed institutional practice) because of its potential to medicalize moral conduct and to vest doctors with power that is likely to be abused.

Given medical control of powerful drugs, I don't see how a right to suicide could exist without medical assistance - but, then, I don't think medical control of powerful drugs is a good idea, either, at least for competent adults.

While I have to agree with you (having looked for the original source of the 90% statistic and come up short) that this statistic is not reliable nor it is traceable to a scientific study or meta-study. But, with that said, I am someone who survived clinical depression. So, I am in the untenable position of knowing for a fact from my own experience that depression does, in fact, cause suicide (I just happened to escape its clutches). I am also someone who believes that suicide is not the preferred way for a human life to end, irrespective of whether one has a philosophical or ethical right to choose it. Perhaps the most rational input for me to make here is to simply say that as a person who is grateful to have survived clinical depression, having gone on to have a productive and relatively happy life, even if there is an ethical right for a person to take one's own life, it seems fully rational for that right to be advocated for only in cases in which the subject is in their most healthy and rational state of mind as opposed to at a time when they are compromised by an ailment of their brain that makes it impossible for them to experience hope or any kind of joy. If a person is going to advocate for the right to die, then it only makes sense that the person who would exercise that right should be healthy and in full possession of all of their rational powers as they make such a final decision. The person who is clinically depressed is certainly not in that state. They are in the most vulnerable position possible to any man and are in the greatest need for the mercy, charity, and advocacy of others. I personally believe that it is against every instinct we possess for a human to take his or her own life. If one is going to choose such a course, it is only right that they do it with the benefit of the full functioning of all their faculties.

I am glad you have found a narrative that makes sense out of your life, even if it's one I personally find creepy. The danger, very commonly acted out, is that people whose narrative becomes "surviving clinical depression" end up imposing their narrative on others who really just want to get out of this awful place.